A 25-year-old woman comes to the office due to a 3-week history of depressed mood, low energy, loss of motivation, and oversleeping following the break-up of a relationship. The patient is sleeping 12 hours each day and describes difficulty getting out of bed and showering and dressing in the morning. Her concentration is poor at work, and she has difficulty completing everyday tasks. The patient has no psychotic symptoms or suicidal ideation. She has a history of major depressive episodes at age 16 and 20. The patient was treated briefly with fluoxetine at age 20 but stopped the medication after a week as she did not like the way it made her feel. Following a rape at age 22, she was treated with trauma-focused psychotherapy for 6 months. The patient has no significant medical history. She drinks a beer several times a week and uses cannabis approximately once every other month. Physical examination is normal. After the physician discusses treatment options for depression, the patient chooses to have combination treatment with psychotherapy and medication. Which of the following would be most important to obtain prior to initiating pharmacologic treatment for this patient?

Question

A 25-year-old woman comes to the office due to a 3-week history of depressed mood, low energy, loss of motivation, and oversleeping following the break-up of a relationship.  The patient is sleeping 12 hours each day and describes difficulty getting out of bed and showering and dressing in the morning.  Her concentration is poor at work, and she has difficulty completing everyday tasks.  The patient has no psychotic symptoms or suicidal ideation.  She has a history of major depressive episodes at age 16 and 20.  The patient was treated briefly with fluoxetine at age 20 but stopped the medication after a week as she did not like the way it made her feel.  Following a rape at age 22, she was treated with trauma-focused psychotherapy for 6 months.  The patient has no significant medical history.  She drinks a beer several times a week and uses cannabis approximately once every other month.  Physical examination is normal.  After the physician discusses treatment options for depression, the patient chooses to have combination treatment with psychotherapy and medication.  Which of the following would be most important to obtain prior to initiating pharmacologic treatment for this patient?

Quizplus · Accepted Answer

All antidepressants can induce mania, with the greatest risk occurring in patients with bipolar disorder. Therefore, prior to initiating antidepressants for a major depressive episode, all patients should be screened for a history of hypomania/mania to rule out bipolar disorder. As many patients tend to minimize or have difficulty recalling periods of mood elevation, physicians should inquire about discrete periods of uncharacteristically good or irritable moods, excessive energy, decreased need for sleep, racing thoughts, and risk-taking behavior. This patient's history of early-onset depression, poor tolerability to a previous trial of antidepressant treatment, and a depressive episode characterized by lethargy and hypersomnia are especially characteristic of bipolar depression and should warrant careful assessment. Patients who have a major depressive episode and meet criteria for a past manic or hypomanic episode should be diagnosed with bipolar disorder rather than unipolar major depressive disorder. Antidepressant monotherapy should be avoided in these patients due to the risk of inducing hypomania/mania. (Choices A, E, and F) Routine screening laboratory tests (eg, complete blood count, metabolic panel, thyroid function tests, urine toxicology screen) are not a priority for this patient with a history of depression and acute onset following a psychosocial stressor, no significant medical history, normal physical examination, and minimal substance use. Selected laboratory tests should be performed in cases of new-onset or treatment-resistant depression or in patients who experience new-onset physical symptoms along with depression. (Choices B and C) Although assessing for comorbid illness such as post-traumatic stress disorder and anxiety disorders would be helpful to gain a deeper understanding of the patient, the most important step in this case is to rule out bipolar disorder. An in-depth trauma history is best obtained by a trained therapist after rapport is established. Educational objective: All patients who have a major depressive episode should be screened for a history of hypomanic/manic episodes to rule out bipolar disorder. This is especially important prior to being prescribed antidepressants due to the risk of antidepressant-induced mania. References: The risk of switch to mania in patients with bipolar disorder during treatment with an antidepressant alone and in combination with a mood stabilizer. (http://www.ncbi.nlm.nih.gov/pubmed/24935197)

A 25-Year-Old Woman Comes to the Office Due to a 3-Week